A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Respiratory rate 16/min

Blood pressure 110/70 mm Hg

400 mL of drainage in the collection chamber within 4 hr

Fluctuation in the water seal chamber with respiration

Answer and Explanation

The Correct Answer is C

A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.

B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.

C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.

D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Medication: The medication, erythromycin, is appropriately prescribed. No clarification is needed regarding the medication.

B. Dosage: The prescribed dosage of 500 mg is a common dose for erythromycin, and there is no indication that it needs to be clarified.

C. Time: The prescription states that the medication is to be given four times per day, but the specific times (e.g., morning, noon, evening, bedtime. are not mentioned. The nurse should clarify the exact timing to ensure proper spacing of doses and avoid interactions.

D. Route: The route is typically oral for erythromycin, and there is no indication that clarification is needed.

A. Verify the amount of TPN solution the client is receiving every 4 hr. B. Place the client in Sims' position for catheter insertion C. Use clean technique when changing the catheter dressing D. Prepare the client for a chest x-ray to verify catheter placement

Correct Answer is D

Explanation

A. Verifying the amount of TPN solution the client is receiving every 4 hours is incorrect. While monitoring the TPN infusion rate is important, the rate and amount are typically verified at the start of the infusion and with each new bag change, not every 4 hours.

B. Placing the client in Sims' position for catheter insertion is incorrect. The preferred position for central venous catheter insertion is Trendelenburg or supine with a slight head turn, which helps dilate the veins and reduce the risk of air embolism.

C. Using clean technique when changing the catheter dressing is incorrect. Central venous catheter care requires sterile technique to prevent infections, including catheter-related bloodstream infections (CRBSIs).

D. Preparing the client for a chest x-ray to verify catheter placement is correct. A chest x-ray is required to confirm correct catheter placement before TPN administration to ensure the catheter tip is in the superior vena cava and to rule out complications like pneumothorax.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

Correct Answer is C

Explanation

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

A nurse is assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has schizophrenia. Which of the following behaviors of the client should the nurse identify as a negative symptom of schizophrenia?

A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client?

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?